PayPal

StatCounter

Monday, September 30, 2013

Never Events

There are good people everywhere. They exist even in bad systems. Good people may actually represent most of the people involved. (As hard as it may be to accept, some evil-doers may sometimes do good works too, confirming that everyone has some redeeming qualities. Of course no one is faultless.) People work to make things better. "Never events" is one example. It was signed into law by President George W. Bush, a person who, like Lyndon Baines Johnson, has few redeeming points in my opinion.) Evil-doers cannot rest easy, even in a corrupt system which they think they control. The clock is ticking and their time is always short. The aggrieved and their champions should never give up hope even as new evils constantly arise.

Having the wrong surgery performed is called a “Never Event” as a result of congressional Act passed in 2006. It was signed into law by President George W. Bush. [7] It directed that a list of Hospital Acquired Conditions (HAC) be recognized and classified as Serious Preventable Errors that should always be preventable by adoption and adherence to evidence based hospital procedures. The US Human Health Department, in collaboration with various highly respected medical organizations, began the congressionally mandated list with eight enumerated serious preventable errors that were to thereafter be known as “Never Events”. Wrong surgery was one of the eight.

[7] Deficit Reduction Act of 2005, Public Law 109-171, 109th Congress stating that the Never Event injury “could reasonably have been prevented through the application fo evidence-based guideline.”

This is bilateral salpingo-oophorectomy http://en.wikipedia.org/wiki/Oophorectomy
The other day, I discussed doctors with a young woman. She is in her mid thirties, I would guess. She knew nothing about hysterectomy. "Do they still do that," she wondered? "I thought most girls had their tubes tied." Winston Churchill said the best argument against democracy is made by having a conversation with any voter for five minutes.

Never events are inexcusable actions in a health care setting, the "kind of mistake that should never happen".[1] The initial list of 28 events was compiled by the National Quality Forum of the United States. They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability."[2]
Several states have enacted laws requiring the disclosure of never events at hospitals and various remunerative or punitive measures for such events. A recent Leapfrog Group Study[3] finds that roughly half of the 1,285 hospitals that responded to their survey waive fees for never events, and that hospitals that do waive fees are much more likely to have perfect scores on the Leapfrog Safe Practices Score survey.
According to a 2012 study published in The New England Journal of Medicine, there are as many as 1,500 instances of 'surgical souvenirs'—instances in which a surgical tool or other foreign object is left inside of a patient's body after surgery—every year in the United States. The same study suggests an estimated total number of surgical mistakes at just over 4,000 per year in the United States; however, these statistics are extrapolations from incomplete data rather than actual event counts.[1]

List of never events

As defined by the National Quality Forum and commonly agreed upon by health care providers, the current list of 28 never events includes:

Artificial insemination with the wrong donor sperm or donor egg

Unintended retention of a foreign body in a patient after surgery or other procedure

Patient death or serious disability associated with patient elopement (disappearance)